Tinnitus Causes and Associations

My aim here is to offer a broad overview of the diverse causes of tinnitus, with future articles planned to delve deeper into some of the specific conditions here (so stay tuned). Each of the following systems are covered:

• Ear Disorders
• Head and Neck Disorders
• Heart Disease
• Metabolic/Endocrine Disorders
• Neurological Disorders
• Psychiatric Conditions
• Autoimmune Disorders
• Infectious Causes
• Trauma Related Causes
• Medication Induced
• Genetic Influences

What causes tinnitus?

Tinnitus is a complex condition involving multiple brain regions and bodily systems, though it is primarily caused by hearing cell loss. With tinnitus, it’s sometimes more accurate to consider associations rather than causes. By doing so, we can gain a more comprehensive perspective on tinnitus and make informed choices regarding treatment.

This article aims to shed light on the myriad influences, associations, and underlying causes of tinnitus. 

What is Tinnitus Prevalence?

Prevalence in epidemiology is the proportion of people who have a specific condition at a given time. Understanding prevalence can help gauge the likelihood of a particular underlying cause that makes tinnitus worse. Here, where the data is available, I present rough estimates of the prevalence of tinnitus across various conditions.

✤ Note: In this study we speak only of subjective tinnitus, not objective tinnitus, such as pulsatile tinnitus. Pulsatile tinnitus is when you hear sounds of your heart beating. The causes of pulsatile tinnitus are distinct and require a whole separate discussion.

How common is tinnitus?

Tinnitus is highly prevalent, affecting roughly 750 million people worldwide. Here are some core tinnitus facts regarding the global prevalence of tinnitus [1]:

Prevalence Category	Tinnitus Prevalence (% of population)
Total prevalence	14.4%
Prevalence of those 45-64	13.7%
Prevalence of those >65	23.6%
Prevalence of severe tinnitus	2.3%

The prevalence of severe tinnitus is important. While tinnitus may be common, what we call “clinically significant tinnitus” is much smaller. This level of tinnitus severity often involves persistent and distressing symptoms that interfere with sleep, concentration, and emotional well-being, leading to substantial impairment in various aspects of life.

✤ Treating Tinnitus: Many doctors tell patients that nothing can be done about tinnitus. This is simply not the case. Protocols developed at my university clinic show clinic response rates between 85-89%.

What ear conditions are associated with tinnitus?

In this section, we will explore ear-related causes of tinnitus, which are among the most common contributors to this condition. Table 1 describes the conditions covered here.

System	Condition	% of Patients with Tinnitus
Ear Conditions	Age-related Hearing Loss	43%
	Noise-Induced Hearing Loss	38%
	Meniere’s Disease	94%
	Otosclerosis	75%
	Sudden Hearing Loss	70%
	Autoimmune Inner Ear Disease	38%
	Vestibular Migraine	40%
	Vestibular Schwannoma	62%

Age-Related Hearing Loss and Tinnitus

Age-related hearing loss (presbycusis) gradually worsens as people age, affecting both ears and primarily impacting high-frequency sounds and the most common reason people use hearing aids. Alongside hearing impairment, it’s one of the most common causes of tinnitus.

In age-related hearing loss, for those with mild hearing loss or greater the prevalence of tinnitus is around 43% [2]. Studies suggest that anyone with moderate to severe hearing loss may benefit from hearing aid use as one of their tinnitus treatment options.

Tinnitus Severity and Hearing Loss

Tinnitus severity increases in people with severe hearing loss. This is because in severe hearing loss, you can’t hear sounds like ambient or background noise. Also because of the more significant loss of cells in the inner ear, the brain cells that produce the tinnitus sound perception are more active. This makes the internal tinnitus signal seem louder.

Hearing aids can help this because hearing aids make ambient sounds louder, essentially providing a form of sound therapy. By getting more sound to the brain cells that perform the function of hearing, we can quiet down those cells. 

✤ Tinnitus Fact: The three most important things you can do to help age-related hearing loss are:

• Use hearing protection when exposed to loud noises (like a loud concert or loud music).
• Take antioxidants daily (antioxidants are important natural remedies for tinnitus).
• Start using hearing aids early on (hearing aid use can decrease your risk of dementia – see below).

✤ Tinnitus Hearing Aids: If you have moderate to severe hearing loss and tinnitus, you can get a ‘combination’ hearing aid programmed to act like a ‘white noise machine‘, providing both sound amplification and tinnitus masking sounds.

Noise-Induced Hearing Loss and Tinnitus

Noise-induced hearing loss (NIHL) is a type of hearing loss caused by exposure to loud noises. The acoustic energy of loud noise results in damage to the hair cells of the inner ear. Prolonged exposure to loud noises can lead to permanent hearing damage and may also trigger tinnitus. It can affect one or both ears, depending on which side had exposure to loud noise.

While tinnitus may resolve in some cases following exposure to loud noises, it can persist as a chronic condition and remain a significant risk factor for developing chronic tinnitus later in life (this is especially true with continued loud noise exposure). Noise damage from shooting a gun or from loud concerts are two common scenarios of noise-induced hearing loss that can lead to permanent tinnitus.

If you have tinnitus, I highly recommend you wear ear protection to reduce your exposure to loud noises to prevent further damage to your hearing. Some patients with tinnitus are more sensitive to loud sounds. 

Estimates of the impact of loud noise on the development of tinnitus vary between studies, but its roughly 22-53%, depending on the age group studied [3-4]. When compared to a people with age-related hearing loss alone, those with a history of prolonged exposure to loud noises had significantly higher tinnitus intensity [5].

✤ Tinnitus Fact: Loud noises from a single loud concert when you’re younger can cause serious damage to your inner ear hair cells and lead to tinnitus later in life. Hearing protection against loud noises is critical if you have tinnitus.

Meniere’s Disease and Tinnitus

Meniere’s disease is a disorder of the inner ear characterized by episodes of vertigo, fluctuating hearing loss, tinnitus, and a feeling of fullness or pressure in the ear. These symptoms are often unpredictable and can significantly impact a person’s balance and quality of life. It can affect one or both ears.

According to research on Meniere’s disease, 94% experience tinnitus and 37% would classify tinnitus as severe [6].

✤ Tinnitus Fact: Our research team recently published a paper showing that Meniere’s disease is a form of atypical migraine. We’re having excellent success rates treating this condition with modified migraine prophylaxis protocols (the same protocols we use to treat tinnitus).

Otosclerosis and Tinnitus

Otosclerosis is a condition marked by abnormal bone growth in the middle ear, particularly affecting the stapes bone, leading to conductive hearing loss. 

Symptoms include progressive hearing impairment, often noticed as difficulty hearing low-pitched sounds, along with a buzzing type tinnitus. It can affect one or both ears, but typically only one ear is affected. The prevalence of tinnitus in otosclerosis ranges from 65-85% [8].

Otosclerosis Tinnitus Treated With Surgery

You can sometimes cure tinnitus from otosclerosis with surgery. A stapedectomy is designed to address the abnormal bone growth by replacing the immobile bone with a prosthesis. A recent review showed that around 85% of people who undergo stapes surgery have a resolution or significant reduction of their tinnitus [8]. Getting your tinnitus diagnosed by a hearing professional is important, because conditions like otosclerosis are easy to spot on an audiogram.

Sudden Hearing Loss and Tinnitus

Idiopathic sudden sensorineural hearing loss (ISSNHL) is a sudden, unexplained loss of hearing that occurs rapidly over a period of a few hours to days. While the exact cause of sudden hearing loss is often unknown, potential factors such as viral infections, vascular compromise, autoimmune reactions, or inner ear membrane ruptures may be underlying causes.

Sudden hearing loss is a common underlying condition in people with tinnitus. It can affect one or both ears, but it’s one sided inn greater than 90% of cases. Around 70% of people with sudden hearing loss report having tinnitus in the affected ear [9]. We have found that sudden hearing is related to an atypical migraine phenomenon, the same atypical migraine that makes tinnitus louder. 

How is Sudden Hearing Loss Treated?

Sudden hearing loss is another potentially treatable cause of tinnitus, but the time window for treatment is very short (it’s considered an ear emergency). Early treatment with steroids (oral and injections behind the eardrum) within one day can have success rates over 70%, but success drops with each day that passes. Some advise using white noise in the early stages to help mitigate the development of tinnitus. 

Controlling the underlying migraine process reduces the likelihood of developing tinnitus. In a landmark study performed at my institution (University of California Irvine), we found that treating sudden hearing loss with migraine medications in addition to standard treatment improves the hearing outcome. 

Autoimmune Inner Ear Disease and Tinnitus

Autoimmune inner ear disease (AIED) is a rare inner ear disorder characterized by inflammation of the inner ear structures, including the cochlea and auditory nerve, resulting from an autoimmune response. AIED may lead to tinnitus as the inflammatory process disrupts normal auditory function, resulting in buzzing, hissing, or ringing in the ears.

The estimated prevalence of tinnitus in AIED is 25-50% [10]. Hearing loss in AIED is fairly rapid (over weeks to months). It can affect one or both ears, but is typically both-sided.

✤ Tinnitus Fact: In approximately 30% of cases, AIED is linked to systemic autoimmune conditions like systemic lupus erythematosus, rheumatoid arthritis, Sjögren’s syndrome, and Wegener’s granulomatosis.

Vestibular Migraine and Tinnitus

Vestibular migraine is a type of migraine that involves dizziness, vertigo, and other vestibular symptoms, often occurring without the typical headache. Vestibular migraine can be an underlying cause of tinnitus. Other ear-related symptoms include ear fullness and hearing loss.

According to a meta-analysis, around 40% of patients with vestibular migraine experience tinnitus as well [11].

✤ Tinnitus Fact: Research by my team has shown that vestibular migraine responds exceptionally well to the same migraine-based protocol we use for tinnitus.

Vestibular Schwannoma and Tinnitus 

Vestibular schwannoma, also known as acoustic neuroma, is a benign and slow-growing tumor that develops on the vestibular (balance) nerve. 

Because they are slow growing and benign, we often just monitor them with annual MRI studies. Surgical intervention or radiation therapy is considered in cases only when the tumor is very large, the tumor enlarges, or brain symptoms develop.

Only in rare cases is vestibular schwannoma the underlying cause of tinnitus. However, for those with the condition, tinnitus is quite common. A large study of vestibular schwannoma patients showed a 62% prevalence of tinnitus [12].

✤ Cochlear Implants: For cases of vestibular schwannoma that require surgery, hearing is generally lost as part of the process. However, the tinnitus typically resolves and hearing can be restored with cochlear implants. 

✤ Imaging Tests For Unilateral Tinnitus: Imaging tests (MRIs) are often performed for people with one-sided (unilateral) tinnitus to rule out vestibular schwannoma as an underlying cause. The good news is that a meta-analysis (analysis of multiple studies) showed that results of these screening MRIs are positive only 0.08% of the time [13].

Vitamin Deficiency and Tinnitus

There are several vitamins and minerals that when deficient, have been associated with tinnitus. These include vitamin D, vitamin B12, magnesium, and zinc. Out of these, the only that reverse when the deficiency is corrected are vitamin D and magnesium.

Eustachian Tube Dysfunction and Tinnitus

Eustachian tube dysfunction involves the improper functioning of the tube responsible for equalizing pressure between the middle ear and the back of the throat. Common causes include allergies, sinus infections, and anatomical abnormalities, leading to symptoms like ear pressure, pain, and hearing difficulties.

In some cases, Eustachian tube dysfunction can be an underlying cause for ringing in the ears. This is because of the subtle hearing loss it causes, making the internal tinnitus sounds seem louder.

Ear Wax and Tinnitus

Ear wax (cerumen) can build up and plug the external ear canal. This ear canal blockage can lead to symptoms such as hearing loss, ear discomfort, and tinnitus. The presence of earwax can create pressure on the eardrum or alter the transmission of sound waves, which can worsen tinnitus.

What head and neck conditions are associated with tinnitus?

Here are several head and neck issues associated with tinnitus that are not directly ear related. 

Temporomandibular Joint Disorder and Tinnitus

Temporomandibular joint disorder (TMD) is a medical condition that involves the jaw joint and surrounding muscles. It often brings symptoms of pain, stiffness, and restricted jaw movement. 

Ringing in the ears can be associated with TMDs due to nerve induced (neurogenic) inflammation of the trigeminal nerve, which is shared between the temporomandibular joint (TMJ) and the ear. The prevalence of tinnitus in patients with TMDs is around 42% [14].

✤ Tinnitus Fact: When people with TMDs experience tinnitus, it’s sometimes called “somatic tinnitus”. This is where pain or movement in the head or neck can worsen tinnitus.

Neck Disorders and Tinnitus

Cervical spine disorders (CSDs) refer to a range of medical conditions affecting the neck. These can include herniated discs, pinched nerves, problems from neck surgery, and more. Symptoms may include neck pain, stiffness, numbness or weakness in the head or neck.

Loud tinnitus is primarily driven by an atypical migraine phenomenon. This migraine process in the brain often causes neck stiffness as well. This stiffness in the neck and shoulder muscles has been erroneously attributed to cervical spine issues.

I have seen several patients who underwent neck surgery thinking it will help their tinnitus and neck stiffness. However, the tinnitus and neck stiffness are brain phenomena and not generated in the neck. The good news is that treating the underlying migraine process will help both the tinnitus and the neck stiffness. 

Headaches and Tinnitus

A headache is a medical condition characterized by aching, throbbing, or pressure sensations in the head or neck. Chronic headaches can cause fatigue, difficulty concentrating, and a decrease in quality of life. The four most common types of headaches linked with tinnitus include tension headaches, migraine headaches, cluster headaches, and sinus headaches. 

Headaches and tinnitus are strongly associated. Based on several studies of tinnitus patients, the prevalence of headaches of any type is around 26-49% [16-18]. Further, patients with severe tinnitus tend to have a higher prevalence of headache [18].

Migraine Headaches and Tinnitus

Migraine headaches are intense and commonly present with symptoms such as nausea, vomiting, sensory hypersensitivity, difficulty concentrating, and more. There is a major shift in the way we understand tinnitus, with new research showing that severe tinnitus is linked to a migraine process in the brain.

In people with a medical history of migraine, 36-45% report concurrent tinnitus [19]. Likewise, in people with tinnitus and headaches, 45% of cases are migraines (even though they are only 12% of headaches in the general population) [20].

Sinus Headaches and Tinnitus

Sinus headaches are almost always migraine headaches in disguise. Many people think they have sinus infections when they feel pressure over the eyes and cheeks. This is different from sinus infections associated with thick nasal discharge when it’s associated with nasal polyps or other infections after getting a cold.

A classic study of 2991 patients with “sinus headaches” (with primary symptoms of sinus pressure, sinus pain, and nasal congestion). Amazingly, 88% of these patients were subsequently diagnosed with migraine by formal criteria [21]. If you think you have sinus headaches, you should get evaluated for migraine.  

Allergies and Tinnitus

Allergies (allergic rhinitis) are characterized by inflammation of the nasal passages and other symptoms such as sneezing, congestion, and itching, often triggered by exposure to allergens like pollen, dust, or pet dander. The approximate prevalence of tinnitus in people with allergies is 41%, much higher than population averages [22].

While allergies themselves do not directly cause ringing in the ears, nasal congestion and inflammation from allergic reactions can affect the Eustachian tube function, potentially leading to ear symptoms including tinnitus.

Does high blood pressure cause tinnitus?

High blood pressure (hypertension) is a medical condition characterized by elevated blood pressure levels persistently above the normal range. Long-term high blood pressure causes small blood vessels to narrow and close. This can contribute to tinnitus by causing changes in blood flow to the inner ear. High blood pressure can also lead to pulsatile tinnitus.

The prevalence of tinnitus among people with high blood pressure is between 41-47% [23-24]. Looking the other way around, the number of tinnitus patients with high blood pressure is similar, around 44% [25].

Other related heart disease conditions such as atherosclerosis (blood vessel thickening), hyperlipidemia (high cholesterol), and chronic heart failure have also been shown to be increased in tinnitus patients vs. non-tinnitus patients [26], [27], [28].

✤ Tinnitus Fact: If you have tinnitus when you are younger (20-40), you have a 2.5 times increased risk of developing high blood pressure [29].

✤ Pulsatile Tinnitus and Intracranial Hypertension: Intracranial hypertension (ICH) refers to increased blood vessel pressure within the skull, often leading to pulsatile tinnitus. ICH is not necessarily associated with high blood pressure.

What endocrine conditions are associated with tinnitus?

Diabetes and Tinnitus

Diabetes is a chronic medical condition characterized by high blood sugar levels resulting from insufficient insulin production or resistance to insulin by the body (insulin doesn’t work as well). 

Diabetes may be associated with tinnitus due to its potential to damage blood vessels and nerves in the inner ear, leading to changes in auditory function and the perception of ringing in the ears.

One study looking at diabetic patients found that 26% also had tinnitus, but the literature on this ranges from 19-64% [30]. Also diabetics lose hearing at a faster rate than non-diabetics and hearing loss is a risk factor for tinnitus. 

Thyroid Problems and Tinnitus

Low thyroid problems (hypothyroidism) can make tinnitus worse because the thyroid hormone imbalances can affect blood flow to the inner ear. This can disrupt the auditory system, which can then worsen tinnitus. Studies show that roughly 21% of hypothyroid patients also have tinnitus [31].

High thyroid problems (hyperthyroidism) is a potential cause of pulsatile tinnitus.

✤ Tinnitus Tip: People with tinnitus and thyroid problems should get their hormone levels checked regularly by their doctor.

What neurological conditions are associated with tinnitus? 

Chronic pain and Tinnitus

One population based study quoted the historical prevalence of tinnitus in chronic pain patients as 54% [32]. Note that this is similar to the prevalence of tinnitus in TMDs, which itself is a form of chronic pain.

This doesn’t mean that chronic pain causes tinnitus. In fact, its chronic atypical migraine which can worsen chronic pain, TMD (temporomandibular joint dysfunction), and tinnitus. The good news is treating the underlying atypical migraine can improve tinnitus and chronic pain. 

Sleep Disorders and Tinnitus

Sleep disturbances refer to disruptions in the normal sleep pattern, which can manifest as difficulty falling asleep, staying asleep, or poor sleep quality overall. 

These disturbances may exacerbate tinnitus symptoms, as the quiet environment during nighttime can make the tinnitus seem louder. Additionally, tinnitus-related anxiety or stress can contribute to sleep disturbances, creating a cycle where poor sleep worsens tinnitus and vice versa. 

In people with tinnitus, the prevalence of sleep impairment of any kind is around 54% [33]. This doesn’t mean that tinnitus is causing the sleep issues but it may be that the patient has sleep issues which causes the atypical migraine issue to be more active and that atypical migraine causes tinnitus to be louder. 

✤ Tinnitus Fact: Tinnitus is worse in the morning and evening for most people, even when adjusting for stress levels. This has led some researchers to suggest that tinnitus loudness is linked to the circadian cycle, our body’s internal clock system [34]. Circadian rhythm disorders are common in atypical migraine which causes tinnitus to become louder.

Insomnia and Tinnitus

Insomnia is a sleep disorder characterized by difficulty falling asleep, staying asleep, or experiencing non-restorative sleep. This leads to daytime fatigue, difficulty concentrating, and impaired functioning. Insomnia may exacerbate tinnitus symptoms as sleep disturbances can increase awareness and sensitivity to tinnitus sounds, making it more difficult to relax and fall asleep.

The prevalence of insomnia in patients with tinnitus is around 52%-60% [35-36]. Again this doesn’t mean that tinnitus causes insomnia, but rather that people with insomnia are more likely to develop atypical migraine, which in turn can make tinnitus louder. 

✤ Treating Tinnitus with Sleep Optimization: One of the best ways to improve treatment results for tinnitus is to optimize sleep. For insomnia, some of the best treatment options are CBT exercises, sleep hygiene measures, light therapy, and daily exercise.

Sleep Apnea and Tinnitus

Sleep apnea is a medical condition characterized by pauses in breathing or shallow breaths during sleep, often accompanied by loud snoring and gasping for air. In one prevalence estimate, roughly 66% of people with sleep apnea report having tinnitus [37].

Sleep apnea causes the activation of atypical migraine, which in turn causes tinnitus. The sleep disturbances and oxygen deprivation associated with sleep apnea is significant enough that we require treatment of sleep apnea as part of tinnitus treatment.

✤ Treating Tinnitus: We always screen our patients for sleep apnea. If the screening is positive, we recommend a sleep study and CPAP therapy if appropriate.

Can tinnitus cause dementia?

Some research is pointing to tinnitus as one of the many possible risk factors for the development of dementia. One case control study found that patients with early-onset dementia had a 67% higher likelihood of having prior tinnitus [38].

We now know that hearing loss is a potentially reversible risk factor for the development of dementia. In this way, getting your tinnitus treated with a hearing aid may actually be protective of your brain.

Can using a hearing aid reduce dementia risk?

According to the NIH, the use of hearing aids among older adults at high risk of dementia reduced the rate of cognitive decline by nearly 50% over a span of three years. They concluded that using hearing aids may be a safe way to lower the risk of dementia.

✤ Tinnitus Fact: If you have hearing loss, getting hearing aids may reduce your risk of developing dementia. If you have hearing loss and tinnitus, you’ll get a double benefit.

What mental health issues are associated with tinnitus? 

Stress and Tinnitus

There is a direct correlation between stress and tinnitus. A review article on the relationship between stress and tinnitus loudness notes that around 53% of tinnitus patients associate stressful situations with worsening tinnitus [39]. This is why tinnitus treated with stress management techniques (like CBT or relaxation therapy) is so powerful.

Anxiety and Tinnitus

Anxiety is a body response to stress, characterized by both emotional and physical symptoms.  In a large population study, 26% of those with tinnitus reported problems with anxiety in the preceding 12 months (vs. 9% without tinnitus) [40].

Clinical anxiety refers to formal disorders like generalized anxiety disorder or panic disorder. Trait anxiety refers to a predisposition towards experiencing anxiety in various situations. Many people with tinnitus many not have a formal anxiety disorder diagnosis, but they do have trait anxiety that contributes to heightened tinnitus distress and sensitivity.

Anxiety, Misophonia, and Tinnitus

Misophonia is a strong aversion to sounds like chewing or tapping. Although tinnitus and misophonia are separate conditions, they exhibit similarities, such as altered function in the attention and habituation parts of the brain.

People with anxiety disorders may be more predisposed to misophonia. Heightened sensitivity and stress responses can exacerbate emotional reactions to triggering sounds, intensifying the distress of misophonia.

Depression and Tinnitus

Depression is a medical condition characterized by persistent feelings of sadness, hopelessness, and loss of interest or pleasure in activities. In individuals with tinnitus, depression can often amplify tinnitus distress. In a large population study, 26% of people with tinnitus reported problems with depression in the preceding 12 months (vs. 9% without tinnitus) [40]. 

✤ Treating Tinnitus: If you have depression, it’s important to have your tinnitus treated in conjunction with a mental health professional.

Suicide and Tinnitus

While tinnitus itself is not a direct cause of suicide, the distress and psychological impact it can have on individuals may contribute to suicidal thoughts or behaviors. People with severe tinnitus experience suicidal ideation at a higher rate than the general population (21% vs 10%), but they don’t actually commit suicide more frequently [41-42].

Note that tinnitus doesn’t cause the suicidal ideation, it is rather the coexisting (sometimes undiagnosed) depression which can lead to these thoughts. So, while thinking about suicide may be common, there’s no increased risk of suicide with tinnitus.

PTSD and Tinnitus

Post-traumatic stress disorder (PTSD) is a medical condition that can develop after experiencing or witnessing a traumatic event, leading to hypervigilance. PTSD may be related to ringing in the ears as the anxiety and depression associated with PTSD can exacerbate atypical migraine which can increase existing tinnitus symptoms. 

In veterans, the high prevalence of both PTSD and noise-induced hearing loss can conspire to worsen and perpetuate tinnitus symptoms, making them more persistent and distressing. In studies from the VA, the prevalence of tinnitus in PTSD patients is around 34% [43].

PTSD and Loud Noises

It’s especially important that people with comorbid PTSD and tinnitus wear hearing protection when around loud noises. Loud noises can trigger a startle response, which can worsen tinnitus and the PTSD symptoms. Hearing protection means avoiding loud sounds as much as it does wearing ear plugs.

✤ Note: The sound reaction in PTSD and misophonia are very similar.

ADHD and Tinnitus

We are just now learning of several fascinating connections between attention deficit hyperactivity disorder (ADHD) and tinnitus. Both ADHD and tinnitus involve the areas of the brain that concern attention and habituation, both respond well to sound therapy, and both conditions share similar triggers in common with migraine.

What autoimmune disorders are associated with tinnitus?

There are multiple autoimmune disorders associated with tinnitus. Here are three common ones, but there are many more.

Sjogren’s and Tinnitus

Sjogren’s syndrome is an autoimmune disorder characterized by inflammation and damage to the moisture-producing glands, leading to dryness of the eyes and mouth. 

While less commonly reported, Sjogren’s syndrome may also affect the inner ear, potentially leading to tinnitus as a result of inflammation or nerve damage in the auditory system. The prevalence of tinnitus in Sjogren’s patients ranges from 10-41% [45].

Rheumatoid Arthritis and Tinnitus

Rheumatoid arthritis (RA) is an autoimmune condition characterized by inflammation of the joints, which can lead to pain, stiffness, and swelling. While RA primarily affects the joints, some individuals may also experience symptoms such as tinnitus.

People with tinnitus are 2 times more likely to have RA than people without tinnitus [46]. It could be that neuroinflammation from RA triggers atypical migraine which causes tinnitus to be louder. 

Sarcoidosis and Tinnitus

Sarcoidosis is a multi-system inflammatory disease that can affect various organs in the body, including the lungs, skin, eyes, and lymph nodes. While the exact cause of sarcoidosis is unknown, it is thought to involve abnormal immune responses. Around 61% of people with sarcoidosis experience tinnitus [47].

Can infections cause tinnitus?

Viral infections can affect the ear by causing inflammation and congestion in the upper respiratory tract, including the nasal passages and Eustachian tubes. This inflammation can lead to changes in pressure within the ear, blockage of the Eustachian tubes, and fluid buildup in the middle ear, all of which can contribute to tinnitus. 

Additionally, viral infections may directly damage the delicate structures of the inner ear, such as the hair cells in the cochlea, which can result in tinnitus as a symptom of inner ear damage.

The Common Cold and Tinnitus

The common cold is a viral infection that affects the upper respiratory tract, causing symptoms such as coughing, sneezing, congestion, and sore throat. Some individuals may experience temporary tinnitus or worsening of existing tinnitus from the common cold due to congestion and changes in pressure in the ear canals caused by nasal congestion and inflammation.

COVID and Tinnitus

COVID has been associated with various auditory symptoms, including tinnitus. Tinnitus is fairly rare in those with acute COVID infection, occurring only around 4.5% of cases [50]. While the exact mechanisms are not fully understood, it’s hypothesized that COVID can lead to inflammation and damage in the auditory system, including the cochlea and auditory nerve, which may result in tinnitus. Additionally, factors such as stress, anxiety, and changes in blood flow associated with COVID infection could exacerbate or trigger tinnitus in susceptible individuals 

Long COVID and Tinnitus

There is a strong link between long COVID (lingering somatic symptoms that last for months after the acute infection) and tinnitus. The prevalence of tinnitus in long COVID patients ranges from 30-73% [51]. We have found a strong relationship between long COVID and atypical migraine, which itself is implicated in tinnitus loudness. 

Middle Ear Infection and Tinnitus

Middle ear infection (otitis media) is associated as the initiating cause of tinnitus in around 61% of patients [48]. There are also significant associations between childhood middle ear infection and tinnitus in childhood and adulthood [49].

Inner Ear Infection and Tinnitus

An inner ear infection is called labyrinthitis. This kind of ear infection is rare, but when it does occur, it’s typically associated with vertigo, hearing loss, and tinnitus. These symptoms typically resolve after the infection, but if the hearing is permanent, there’s a stronger change that tinnitus will also become chronic.

Can traumatic injury cause tinnitus?

Rare severe injuries to the head (e.g. skull fracture) can be associated with tinnitus. Blast injuries from explosions are strongly associated with tinnitus.

Head Injury and Tinnitus

In our 20 years of experience in a level 1 trauma center we have found that traumatic brain injury (TBI) only causes tinnitus when associated temporal bone fracture occurs. This kind of injury can be related to tinnitus, because some temporal bone fractures cause damage to the hearing system. 

Temporal Bone Fracture and Tinnitus

A temporal bone fracture is a break or crack in the bone that forms part of the skull’s temporal region, housing delicate structures like the inner ear and auditory nerve. Such fractures can be related to tinnitus when they cause damage to the important ear structures or auditory nerve, disrupting normal auditory function and leading to symptoms like ringing or buzzing noises in the ear. 

Blast Injury and Tinnitus

A blast injury refers to physical trauma caused by the rapid release of sound energy from an explosion, often resulting in damage to various body structures. Blast injuries can affect the ears by causing damage to the eardrum and inner ear, leading to hearing loss, vestibular dysfunction, and tinnitus.

In one meta-analysis people who were in close vicinity of a bomb explosion, 85% had tinnitus as a symptom in the first month after the event [53].

What medications can cause tinnitus?

Ototoxic medications are drugs that can harm the inner ear, potentially causing hearing loss, balance issues, and tinnitus. Additionally, ototoxic drugs may cause inner ear blood vessel damage or induce inflammation, which can in turn worsen tinnitus symptoms.

Here are some ototoxic medications known to be associated with tinnitus:

• Aminoglycoside antibiotics (e.g., gentamicin, amikacin)
• Loop diuretics (e.g., furosemide)
• Chemotherapy (cancer drugs like cisplatin)
• Nonsteroidal anti-inflammatory drugs (NSAIDs) (e.g., ibuprofen, aspirin) (reversible)
• Quinine and its derivatives (e.g., chloroquine)
• Antimalarial drugs (e.g., chloroquine, mefloquine)
• Salicylates (e.g., aspirin) (reversible)

Sometimes a single dose will not cause a problem, but prolonged exposure will. Some drugs you can avoid, but with medications you must take (like cancer drugs), there are certain antioxidants and supplements that may provide a measure of hearing protection. 

If you’ve taken one of these ototoxic medications and develop ringing in the ears, it’s important to have your tinnitus diagnosed with a formal hearing test.

Vaccines and Tinnitus

Vaccines work by introducing a weakened or inactive form of a bacteria or virus to stimulate the immune system, prompting it to produce antibodies that provide immunity against future infections. In rare cases, vaccines may trigger an inflammatory response in the body, activating the migraine process which leads to worsening of tinnitus. This has been reported with the COVID vaccine.

Genetic Causes of Tinnitus

Our understanding of how genetics influences tinnitus is just beginning. There are many genes in tinnitus that overlap with those seen in hearing loss. There is very little know currently on the genetic predisposition to tinnitus. We do know that tinnitus sometimes runs in families likely due to the genetics of atypical migraine. 

Conclusion: Tinnitus Treatment Options are Available!

This long list of medical conditions associated with tinnitus reveals some underlying causes that can be addressed directly. In other cases, standard tinnitus treatment options can be used. Here are the some common things you can do to get your tinnitus treated properly:

• Get Tinnitus Diagnosed The Right Way: As noted above, getting tinnitus diagnosed properly with a formal hearing test by an audiologist is important. The hearing test can sometimes help them spot an underlying condition that is treatable. Having your doctor review for all of the health conditions that are risk factors for tinnitus is also important. Some medical conditions must be addressed alongside formal tinnitus treatment.

• Hearing protection: Any prolonged exposure to loud sounds can make tinnitus worse. The most appropriate hearing protection is avoidance of loud sounds (a loud concert, loud music, etc.). Wearing plugs in the ear canal is OK short term, but with tinnitus, you generally want a noise-enriched environment. For health conditions like hyperacusis, misophonia, or PTSD, ear protection against loud sounds is especially important.

• Hearing Aids: Use of a hearing aid is a good place to start if you have hearing loss. If you get your tinnitus diagnosed by a tinnitus specialist, you can consider getting a combination hearing aid that provides tinnitus masking (it’s like a mini white noise machine). These can be worn in the ear canal or behind the ear.

• Sound Therapy: People with tinnitus should always consider having their tinnitus treated with sound therapy. This can start with a simple white noise or some other background noise; from a fan, air purifier, or nature sounds from a white noise machine. Remember, tinnitus sounds louder when it’s quiet.

• Online Tinnitus Retraining Therapy: At NeuroMed, we do online tinnitus retraining therapy. There are several differences between classic tinnitus retraining therapy and NeuroMed therapy:

• Instead of white noise, we use a customized sound file that has been shown in clinical trials to be superior to white noise.
• Psychoeducation is performed through online CBT and with an advanced practice provider who can prescribe medications (vs. an audiologist).
• Because we use an integrative medicine approach, instead of taking 1-2 years, our online tinnitus retraining therapy program is condensed to 20 weeks.

If you’re interested in getting comprehensive, science-backed tinnitus care, schedule a free pre-enrollment consultation with our team to see if the NeuroMed program is right for you.

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